Left cerebellar infarct with hemorrhagic transformation

Case: Referred from KKB. 57 years old malay male with underlying hypertension went to KKB with full GCS, complained of headache, nausea, vomiting, for 2 days with generalised body weakness. no fever. He was started on iv GTN due to uncontraoled hypertension. At 6pm he was confused, having slurred speech with gsc of E4V2M5. He was then referred to HSB for CT brain

PHYSICAL EXAMINATION General : gsc E4V2M6 pupils 3/3

Head and Neck : NAD

CVS : DRNM

Respiratory : Clear Abdomen : soft, nontender, bowel sound heard

Musculoskeletal System : moving all 4 limbs

CT scan on 16/6/2009

Finding: Ill defined hypodense area seen in the left cerebellar hemisphere with perilesional oedema. The cerebellar fovea are effaced with effacement of the 4th ventricle with resultant dilatation of both lateral ventricle * 3rd ventricle. Area of hyperdensity within suggesting intraparenchymal bleed. No midline shift. Quadrigeminal cisterns are narrowed. Visualized sinuses and mastoid air cells are clear.

IMP: With the given presentation, the findings are suggestive of cerebellar infarct with haemorrhagic transformation. Associated with dilatation of lateral ventricles and 3rd ventricle due to mass effect of the 4th ventricle.

He underwent right frontal EVD placement. Right frontal EVD inserted (17/6/09)

Post-op patient alert
E4V3M6
Pupils 3/3 reactive

The next day, Informed by staff nurse that pt was not opening eyes to call / not obeying commands + stridorGCS dropped from 13/15 to 7/15 ( E1V1M5 )Pupil : 3/3 ( reactive )B/P : 240/125PR : 111spo2 : 94 %

He was immediately intubated stat using ETT size 7.5 and started on IV midamorphine infusion 5ml/HLatest B/P : 192/113PR : 98Spo2 : 100%

Repeat Ct scan on 18/6/2009

Finding: ***comparison with CT Brain dated 17/6/09. Evidence of right parietal craniotomy with EVD traversing the right parietal lobe with tip at adjacent to the wall of right lateral ventricle. The previously noted hypodense area seen in the left cerebellar hemisphere with perilesional oedema is now more well defined. The intraparenchymal bleed in the left cerebellum remains similar in appearance.No new bleed. The cerebellar fovea are still effaced with effacement of the 4th ventricle. There is increasing dilatation of both lateral ventricle and 3rd ventricle. No midline shift. Quadrigeminal cistern is more narrowed.

Imp: Increasing hydrocephalus with narrower quadrigeminal cistern. No new bleed/ expansion of bleed.

He was brought to OT for posterior fossa decompression.

Post-op he was on cerebral protection with ICP maintained below 20mmHg.

Post-op CT scan on 19/6/2009

Finding: ***comparison with CT Brain dated 18/6/09. Evidence of right parietal craniotomy with occipital craniectomy . The intraparenchymal bleed in the left cerebellum remains similar in appearance.No new/expansion of bleed. 4th ventricle is no longer effaced. There is minimal reduction in the degree of dilatation of both lateral ventricle and 3rd ventricle. No midline shift. Quadrigeminal cistern is still narrowed.

Imp: Decreasing hydrocephalus. No new bleed/ expansion of bleed.